Molar distalization

MOLAR
DISTALIZATION
www.indiandentalacademy.com

 Class II Malocclusion
 Non-Extraction treatment
 Non-Compliance therapies
 Treatment - Molar Distalization
 Space regaining procedure
-Mesial migration of first permanent molars

Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch
length of about 2mm on each side.
2. Late mixed dentition
- When lower E space –utilized for relief of
anterior crowding,
- Upper molars distalized to get a class I
relation

3. Non-growing patient
- To regain lost arch length
- Blocking out of canines
4. Upper second molar extraction
- Lower arch normal

 Class I malocclusion- with highly placed canine/impacted
canine
 Lack of space for eruption of premolars due to mesial
migration of permanent first molars

 End on molar relationship
with mild to moderate space
requirement
 Cases with less than a full
cusp class II molar
relationship

 Good soft tissue profile
 Borderline cases
 Mild to moderate space
discrepancy with missing 3rd
molars/2nd
molars not yet
erupted

 Axial inclination : Mesially
angulated upper molars
 Normal or Hypodivergant
growth pattern
 Late mixed dentition with
mild crowding of anteriors

Case selection
1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary
tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars placed normally- buccolingually
4. 3rd
molars-absent –stacking of upper molars – unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effect
7. Space discrepancy- not very severe

Classification
1. Location of appliance
 Extra-oral
 Intra-oral
2. Position of appliance in mouth
 Buccal
 Palatal
3. Type of tooth movement
 Bodily movement
 Tipping movement

Classification
4. Compliance needed from patient
 Maximum compliance
 Minimum or No compliance
5. Type of appliance
 Removable
 Fixed
6. Arches involved
Intra-arch
Inter-arch

Various appliances used for Molar
Distalization :
 Headgears
 Wilson Bimetric arch design
 ACCO
 Crozat appliance
 Crickett appliance
 Modified Nance Lingual appliance
 Non-extraction treatment
 Schmuth and muller double plates
 Molar distalization with magnets

Various appliances used for Molar
Distalization
 Use of Super elastic NiTi
 Jones Jig
 The Pendulum appliance
 Claspring
 Removable molar distalization splint
 Fixed piston appliance
 The K-loop appliance
 The distal jet
 Using Implants
 Fixed functional appliances

Distalization using Headgears
 Very efficient
 Reciprocal forces are not transmitted to other teeth
 Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force

Biomechanics of Headgears:
 C Res
 Moments

Straight pull headgear
 Class II Malocclusion with
no vertical problems
 Prevent anterior migration
of maxillary teeth, translate
them posteriorly
 Buccal force to molar -
Expansion of inner bow

Cervical Headgear
 Short face Class II
maxillary protrusive
cases with low MPA
& Deepbites
 Extrusive & distalizing
effect

High pull Headgear
 Produces intrusive &
Posterior direction of pull
 Long face class II
patients with high MPA
 Force through c res –
Intrusion & distal
movement of molar
 6-8 months – class II-
classI
Adv-effective, no reciprocal forces
Disadv- Patient compliance

Bimetric system for Molar Distalization
 Dr.Wilson-Tandem yoke
with bimetric arches for
molar distalization
 Tandem yoke-.045” round
tube – slides on .040” end
section of the bimetric
loop.
 .018 retractor
 .045” coil spring for
distalizing
 Intermaxillary traction

 Coil spring- between molar
tube & the yoke
 Elastics- 12 hours a day
 Headgear – at night
 The Omega adjustable
stop –to modify & control
arch length
 Crimpable .040”tube
 .061 Omega loop
 Coil springs &
intermaxillary hooks.

Bimetric arch modified by Dr. Jayade
 Class II correction- Distalization + expands canine-
premolar area- unlocks the occlusion
 A mild-moderate class II div 2 with normal mandibular
arch-easily corrected

Bimetric arch modified by Dr. Jayade
Archwire design:
 .016”premium wire
 Premolars bonded if
expansion is required
 Teardrop shaped loop
 Bite opening bend
 Mild toe-in
 2mm activation

Elastic load reduction principle:
 Class II elastics – used sequentially
T.P Green – 1st
week
Pink - 2nd
week
Yellow – next 2-3 weeks
 Initial heavy force- to resist forward
pushing force of new wire- force
transferred distally
 Later Molar uprights-mesially directed
archwire force decreases- support with
light forces.
 Extrusive component of class II- kept to a
minimum
Borderline cases –Non extraction

ACCO Appliance JCO1969
 Removable appliance with headgear
 Distal mass movement of buccal segments
 Dr.Leonard Margolis – harness growth-
later springs added for distal tooth
movement

 Northwest Headgear-
12hrs/day, counteracts
anterior component of force
Appliance design:
 Labial bow: .022 x .028 wire
 Loops to receive NWHG
between the central and
lateral on each side
 Wire covered with acrylic
for good retention

Appliance design:
Clasps :.030 or .031 wire
Modified ring clasp
Finger springs : .021 X .025
Acrylic :3-4 mm away from
lingual surfaces of teeth
distal to lever arm of finger
springs
Enough bite plane in anterior
segment, so that the
posterior occlusion is just
cleared when the lower
anteriors are in contact
with the bite plane

Treatment progression :
A. Placement of finger springs for first appliance
 If 7,6,5,4 present, 2 finger springs engaged
B. Second appliance
 After distalization on one side
 Leave first appliance as retainer
C. Cuspid retraction
 Third appliance to retract both cuspids

Nonextraction treatment
Cetlin & Ten Hoeve, JCO 1983
Space Gaining in the Mandibular Arch With the Lip Bumper
 .045 SS wire covered with tubing
 U-shaped loops – adjustment areas
And stops mesial to the molar tubes.
 Placed on most distal molar
 Recent studies- Ram Nanda etal
- AJO 1991 Jun
Posterior movement of mandibular incisors are very minimal

Space gaining in the maxillary arch
 Combination of extraoral force and
an intraoral force
Inraoral
 Anchorage – adaptation to palate &
acrylic shield around incisors
 Bite plane
 Adams clasp on premolars
 Springs on molars activated by 1-1.5
mm – force -30 gms
Exraoral
 Cervical or high pull headgear
150 gms / side ; 12 -14 hrs/day

Palatal bar as an adjunct in space
gaining in the maxillary arch
 Unilateral distalization

Modified Nance and Lingual appliances
for unilateral tooth movement Ghafari JCO 1985
Nance holding arch :
 Palatal arch attached to first
molar bands , embedded in an
acrylic "button"
 space maintainer in the
maxillary arch,
 support maxillary posterior
anchorage during tooth
movement
Modified Nance holding arch and
modified lingual arch:
 Anchorage for unilateral
distalization of posterior teeth
 No patient compliance required

for unilateral tooth movement
Modified Nance holding arch
 12 yrs/M
 Skeletal & Dental class I
 Right side- distoocclusion
 2nd
premolar- 3.5 mm space
 R – 1st
PM & molars banded
 Segmental .019 x .025 NiTi
 Open coil spring
 4 months
 No labial movement of
incisors

for unilateral tooth movement
Modified Lingual arch
 13 yr /F
 Skeletal class I
 Lingually positioned R 5
 3.2 mm space
 Lingual arch from L6 to R4
 Coil spring from R 4-6 on a
segmental .019 x .025 NiTi

K-Loop Molar Distalizing Appliance
Valrun Kalra – JCO 1995
 K-loop – forces - .017 x .025 TMA
 Nance button – anchorage
 8mm long , 1.5 mm wide
 Legs- 20 degree bend
 Inserted into molar and first
premolar tube, marked
 Stops bent 1mm distal , 1mm
mesial
 Stops- 1.5mm long

K-Loop Molar Distalizing Appliance
Valrun Kalra – JCO 1995
 Reactivated 2mm 6-8
weeks later
 Molars move by 4mm,
premolars by 1mm
 Anchorage can be
reinforced by headgear

K- loop Appliance

Removable molar distalization splint
Dr. Karrodi Ritto JCO 1995
 Splint – 1.5mm Biocryl-Biostar machine
 More esthetic & comfortable
 Bilateral- 1st premolar- 1st
premolar
 Unilateral – Premolar – Opposite Molar
 Two internal clasps – retention
 NiTi open coil spring- 220 gm force
 1.5mm-2mm/month

Distalization of Molars with
Repelling Magnets Gianelley etal JCO 1988
 Anchorage – Modified Nance
appliance
 Wire extending from 1st
premolars
 Acrylic button anteriorly
contacting the incisors
 Auxillary wire with a loop at its
end soldered - premolars bands

Distalization of Molars with
Repelling Magnets
 Incisor brackets – passive
sectional wire- maintain incisor
alignment
 Repelling surfaces of magnets
brought into contact by passing
an .014 ligature through the loop,
then tying back a washer anterior
to the magnets
 Force- 200-225 gms , dropped as
space opened
 3mm in 7 weeks
 Anchor loss – 1mm

Japanese NiTi coils used to move
molars distally -Gianelly AJO 1991
 100 gm superelastic coils
 Nance appliance with bite plate
in anterior region
 .016 x .022 wire with stops
abutting distal wings of
premolar and molars
 Coil – between 1st
premolar and
the molars
 .018 “ uprighting spring placed
in vertical slot of
premolars,directing crowns
distally

Japanese NiTi coils used to move
molars distally
 2nd
molars erupted- Class II elastics
 Rectangular wire – 10 degree lingual root torque
 Once distalized, Coils &Nance appliance are removed, insert
.016 x .022 “ wire with stops + High pull headgear to upright
roots of molars

Molar distalization with Superelastic
NiTi wire Gianelly JCO 1992
 100gm Neosentalloy upper
archwire
 3 markings
 Stops crimped, hook added
 Insert wire such that posterior
stop abuts mesial end of molar
tube, anterior stop abuts distal of
premolar
 Anchorage reinforced by class II,
or Nance appliance

Molar distalization with Superelastic
NiTi wire
Case report :
 12 yr / F
 Unilateral class II
 Class II against upper 1st
premolar
 Overcorrected- 4 months

NiTi Double Loop system for
simultaneous distalization of first
and second molars Giancotti JCO 1998
 Mandibular molars and 2nd
premolars
banded, other teeth bonded
 Lip bumper- prevent extrusion
 Maxillary molars and bicuspids –
banded, aligned
 80 gm Neosentalloy – maxillary
archwire placed – marked
1. Distal to 1st premolar
2. 5mm distal to 1st
molar tube
 Stops crimped on markings

and second molars
 Sectional NiTi archwires –
crimp stops
1. Mesial and distal to 2nd
premolar
2. 5mm distal to 2nd
molar
tube
 Uprighting springs on 1st
bicuspids
 Class II elastics
 Simultaneous, bodily
movement
24yr/f, class II div I
5months- overcorrected

and second molars
 Minimal patient co-operation
 Ideal for simultaneous distalization
 Anchorage easily controlled , without need for TPA/Nance
 Due to streching of transeptal fibres, 1st
molars can be
distalized using lighter 80 gm force

Pendulum Appliance for class II
non-compliance therapy
JAMES J. HILGERS,JCO 1992
 Nance button
 .032 TMA springs
 Broad swinging arc
(Pendulum) of force from
midline of palate to upper
molars

Pendulum Appliance
Fabrication :
Pendulum springs consist of
1. Recurved molar insertion
wire
2. Horizontal adjustment loop
3. Closed helix
4. Loop for retention in acrylic
button
 Springs- close to center of
Nance button
 Anterior portion- retention-
occlusally bonded rests
- Band
upper 1st
premolars, solder
retaining wire to the bands

Pendulum Appliance
 Nance button- extend to about 5mm
from teeth
 Anterior retention loops fixed on
model, later soldered to bicuspid
bands
 Acrylic pressed against the palatal
vault
 Pendulum springs inserted

Pendulum Appliance
Pend-X
Jack-screw-One-quarter turn
every 3 days

Pendulum Appliance
Preactivation and placement:
 Springs bent parallel to midline of the
palate
 Molar bands cemented
 Anterior portion of appliance later
cemented
 Pendulum spring brought forward &
engaged in lingual sheath
 As molar distalizes, moves on an arc
towards midline- counteracted – opening
horizontal loop

Pendulum Appliance
 Reactivate if required
 Reavtivated by pushing it distally towards the midline
 Stabilize after correction
 Nance appliance
 Full arch bonding – continous wire with omega loop
 Headgear for few months

Pendulum Appliance
 Unilateral correction

Pendulum Appliance
Conclusion :
 Excellent patient tolerance
 Upto 5mm distalization in 4 months
 Distalization + Expansion
 Patient compliance not needed
 Modified Pendulum Appliance- Scuzzo- 2000 April
Removable arms

Removable pendulum

Franzulum appliance
Friedrich Byloff et al JCO2000 sep
 Anterior anchorage :
acrylic button-5mm wide
 Rests on canine and
premolars - .032 wire
 Tube from acrylic button
to receive active
component
 NiTi coil springs-100-
200g/side
 J-shaped wireinserted
into tube

Franzulum appliance
 Anchor unit bonded with composite
 J-shaped distalizing unit ligated to
lingual sheath
 Active component close to C Res
Case report
 11yrs 10mts / M
 end on molar relationship
 Space deficiency in both the arches
 Premolars blocked out
 Upper pendulum and lower Franzulum
 Nance holding arch
 Fixed appliance with cervical headgear
and Cl II elastics
 End of treatment; Class I molar
relation, no signficant. Change in facial
profile

Open Coil Jig
Jones, White –JCO 1992 Oct
 Richard D. Jones
 American Orthodontics
 Open coil NiTi spring
 Nance appliance

1. Heavy round wire
2. Light wire
3. Fixed Sheath
4. Hook
5. Sliding Sheath
6. Open coil spring
3
1
2
5
6
4
Open Coil Jig

Open Coil Jig
 Reactivation
 4-5 mm distalization in 3-4 months
 Advantages…
 Disadvantages-
-Tipping
- Cannot use with fully banded treatment
- Breakage

Lokar Molar Distalizing Appliance
A- Inserts into molar attachment with a rectangular wire
B- Compression spring
C- Sliding sleeve
D- Groove
E- Flat guiding bar
F- Round posterior guiding bar
G- Immovable posterior sleeve

Lokar Molar Distalizing Appliance
 Nance button
 Can be used in conjunction with complete edgewise
appliance
 With headgear
 Easy insertion, activation

Distal jet Appliance
Aldo Carano, Mauro Testa JCO 1996
 Fixed lingual appliance
Appliance design :
 Wire extending from acrylic
through tube ends in a bayonet
bend-inserted into lingual sheath
 Coil spring
 Clamp
 Anchor wire to 2nd
premolar

Distal jet Applaiance
Aldo Carano, Mauro Testa JCO 1996
 Reactivation- sliding clamp
closer to first molar
 After distalization –
- clamp-spring assembly-
acrylic,
- premolar arms cut off.

Case report
 18/F, Class II divI
 No skeletal abnormalities
 Non-extraction therapy (3rd molars
removed)
 Distal jet
 4 months- Class I ,2mm-L, 3mm-R

Advantages :
 Bodily movement
 Easy insertion
 Well tolerated
 Esthetic
 Unilateral, Bilateral
 Permits simultaneous use of full bonded appliances

Modifications of Distal jet Appliance
Andrew Quick, Angela Harris JCO 2000
Earlier :
 Sliding collar-tightened- small set
screw- Allen wrench
Modification :
 Rear entry of sliding section into the
molar sheath
 Sliding wire- .032 “
 Stop collar soldered to wire
 Activation
 Retention- solid tubing

Fixed piston appliance - Greenfield
 .036 “ tubing- soldered to
biccuspids
 .030 “ ss wires- first molars
 Nance button
 NiTi coil

Unilateral Distal Molar Distalization
movement with an Implant
supported Distal jet appliance
Karaman et al- Angle Orthodontics-2002
Case :
 11yr/M
 Well balanced face
 Straight profile
 Class II molar relation on left side
 Super class I on right side
 Mandibular teeth- favorable alignment
 Upper left 2nd
premolar impacted
 ANB- 0 degrees

Treatment objectives :
 Class I molar relation
 Eruption of impacted molar
 Controlled eruption of erupting teeth
Treatment alternatives
 Extraction of L 1st premolar
 Extraction of L 1st
premolar
 Distalization of upper left molar

Appliance fabrication :
Molar bands with palatal tubes
Anchorage screw- 3mm dia, 14 mm
long
Anterior palatal suture, 2-3 mm
posterior to incisive papilla
Impressions for appliance
construction
1mm tube adjusted to implant

 Anchor wires .8mm-soldered to
tubes for occlusal rests on
premolars
 .9mm wire extended through each
tube ending in a bayonet bend-
palatal tube of molar
 NiTi open coil spring – active on left
side only
 Appliance attached to premolars –
composite
 Joint between implant & tube-
secured with composite
 2 months- 4.5mm distalization
 Space for canine-maintained

Conclusion
 Borderline cases
 Space gaining procedures
 Simplicity
 Clinical effectiveness
 Patient compliance factor

Molar distalization

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